Recent Hypertension Guidelines Lawrence J. Fine, MD, DrPH, FAHA Division of Cardiovascular Sciences NHLBI/NIH February 19, 2014 Disclosures: Member of Panel Appointed to the Eighth Joint National Committee (JNC 8) Million Heart Campaign wants to build on the accelerating progress of the last twenty years The Million Heart Campaign is building on the accelerating progress of the last twenty years “Getting warm …. warmer.”  Look at CVD mortality for those < 75 years old.  Nearly one fourth of all CVD death avoidable.  56% of the avoidable deaths in those < 65 (important target for primary prevention).  Some of these „avoidable‟ deaths are likely due to lack of preventive health care or timely and effective medical care. “Avoidable” Deaths from Heart Disease, Stroke, and Hypertensive Disease – United States, 2001 - 2010 MMWR September 6, 2013 Age Groups CVD Death s in 2001 CVD Death s in 2010 Percent Decline in Death Rate (p < .05) 35 -54 46,426 43,884 -6% 55 -64 61,105 65,680 -27% 65 -74 117,66 2 87,741 -37% Number of Avoidable Deaths from CVD – United States, 2001 -2010 MMWR 9/26/2013 Schieb LJ Race/Ethnic ity and sex 2001 Rates per 100,000 2010 (% Decline over 10 years p < .05) Asian Females 36 22 ( -39%) White Men 112 81 ( -28%) Hispanic Men 93 63 ( -28%) Black Men 200 143 ( -28%) MMWR 9/6/2013 Schieb Rates of Avoidable Deaths Data Illustrates Murray‟s Eight Americas: New perspectives on U.S. health disparities Asian men 47 Disentangling Complexity is Challenging – Why did CVD decrease and how can we make additional progress? http://www.smallmanart.com/2012/07/05/disentangling-complexity.html - © Stefano Masini 2012 146 133 122 139 108 100 110 120 130 140 150 160 1988-1994 1999-2002 2007-2010 Age Specific LDL mg/dL in Adults 60-69 Carroll et al. 2012 JAMA Wom en A Partial Answer: Trends in LDL 1988-2010 125 130 135 140 145 2000 2002 2004 2006 2008 2010 Age Adjusted SBP in Adults 60 + Yrs. 1999 to 2010 NHANES Guo et al. 2012 JACC Another Contributor with a Different Secular Pattern 10 mm Delta No Change 1988 to 1999 Disentangling Complexity is Challenging – Many new guidelines? http://www.smallmanart.com/2012/07/05/disentangling-complexity.html - © Stefano Masini 2012 [...]...Four New Guidelines  2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8)  American Society of Hypertension and the International Society of Hypertension Clinical Practice Guidelines for the Management of Hypertension in the Community  2013 European Society of Hypertension/ European... College of Cardiology released four cardiovascular treatment guidelines for healthcare providers in November, and next year they will be updating their high blood pressure guidelines as well The new report that was published in JAMA… will be taken into consideration for those guidelines, which will be the national standard for treating hypertension Until then, the AHA/ACC recognize the most recent hypertension. .. frank: "This article is not intended as an attack on the 2014 hypertension guidelines The purpose of this Annals commentary was to clarify the rationale behind the defense of keeping the 140 mm Hg target, rather than raising it to 150 mm Hg.”  Lot of dialogue and mutual respect on the Panel Differing Perspectives on Whether There Was Evidence of Benefits Majority Perspective  HYVET, Syst-Eur and... of Cardiology Guidelines Four New Guidelines  Each set of these guidelines was independently developed They used different methodologies and criteria for reaching their conclusions and varied in how comprehensive their recommendations were  All acknowledged that many key questions remained unanswered and called for greater research Systolic Blood Pressure Treatment Goals and Thresholds  Areas of. .. Michael L LeFevre, MD, MSPH7; Thomas D MacKenzie, MD, MSPH8; Olugbenga Ogedegbe, MD, MPH, MS9; Sidney C Smith Jr, MD10; Laura P Svetkey, MD, MHS11; Sandra J Taler, MD12; Raymond R Townsend, MD13; Jackson T Wright Jr, MD, PhD14; Andrew S Narva, MD15; Eduardo Ortiz, MD, MPH16,17 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the... Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) Guideline Goal BP and Initial Drug Therapy for Adults With Hypertension JAMA 2014; 311(5):507-520 doi:10.1001/jama.2013.284427 Date of download: 2/11 /2014 Copyright © 2014 American Medical Association All rights reserved Recommendation One: The Corollary Recommendation  Corollary Recommendation - … if pharmacologic...  2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) Paul A James, MD1; Suzanne Oparil, MD2; Barry L Carter, PharmD1; William C Cushman, MD3; Cheryl Dennison-Himmelfarb, RN, ANP, PhD4; Joel Handler, MD5; Daniel T Lackland, DrPH6; Michael L LeFevre, MD, MSPH7; Thomas D MacKenzie, MD,. .. Syst-Eur and SHEP showed benefit but had average SBP in the active arm of between 143 and 150 mm Hg  Only two other goal trials (JATOS and VALISH), while having limitations, provided no evidence of benefit of 145 vs 135 mm Hg Minority Perspective  Evidence from trials and observational studies that the panel did not use as part of its review supports the lower goal, especially in high-risk patients...  “No 1, it's going to simplify the goals (of treatment because) there are only two goals to remember No 2, I do think a lot of physicians who take care of the elderly have been concerned over the years about the potential for causing harm by overtreating blood pressure." It's certainly not uncommon for elderly patients to become dizzy on standing because of the antihypertensive medication or medications... on health or quality of life, treatment does not need to be adjusted (Expert Opinion – Grade E) Other Views http://www.ash- us.org/documents/ASH_ISHGuidelines_2013.pdf Where ASH and the JAMA JNC Paper Agreed  “The treatment goal for systolic blood pressure is usually . Recent Hypertension Guidelines Lawrence J. Fine, MD, DrPH, FAHA Division of Cardiovascular Sciences NHLBI/NIH February. Practice Guidelines for the Management of Hypertension in the Community  2013 European Society of Hypertension/European Society of Cardiology Guidelines  2013 Canadian Hypertension Guidelines. Cardiology Guidelines  2013 Canadian Hypertension Guidelines Four New Guidelines  Each set of these guidelines was independently developed. They used different methodologies and